A case in point…

…just to illustrate the bind that the homebirth midwives find themselves in at the moment after the closing of St. Vincents hospital and the subsequent loss of their back-up hospital/ written practice agreements (see yesterday’s post):

Last night I was working (at the HHC public hospital in Brooklyn where I spend a good deal of my time) and I received a phone call from a sister midwife who works with me at the same hospital. She had just been contacted by a mutual midwife friend who had been contacted by a homebirth midwife who was in the middle of attending a difficult delivery last night and was considering a transfer to a hospital. While I don’t know all of the details of the birth, I do know that the woman had been fully dilated for several hours already, and had been pushing without much success, and it was getting to the point where the homebirth midwife was beginning to think that a vacuum-assisted delivery might be necessary, hence the need to transfer to a hospital/ MD care. What the homebirth midwife was most concerned about was the possibility of an MD at a hospital turning her in to the authorities for practicing without an official back-up physician/ written practice agreement. Nevertheless, any woman in labor coming to any hospital is entitled to immediate emergency care, and cannot be turned away, thanks to EMTALA laws. The problem is that if the midwife attending her does not have admitting privileges and/or a WPA at the hospital where they transfer to, she has limited authority and cannot necessarily continue to manage the patient. In other words, the midwife would have to act as a monitrice (midwife at home, doula in the hospital), which is disappointing and frustrating, to say the least, especially for the woman in labor who was relying on her midwife’s judgment and management. It pretty much destroys the continuity of care between midwife and client if a transfer to a hospital is required.

And then, of course, there’s the relationship to consider between the midwife and the hospital she’s transferring to. If the relationship has not been established in advance, the midwife is walking into a situation where she may not know or be familiar with the attending on call, may not have any say or influence in the continued management of the patient, and may actually be judged and excoriated (at the best) and potentially turned into the authorities (at the worst). The hospital outlook towards women attempting homebirth, and the midwives who attend them, can be outright cruel. I have heard MDs muttering under their breath before about how “criminal” and “dangerous” it is to give birth at home. It doesn’t help, of course, that the women who transfer to a hospital are only transferring because something went wrong, or because they need something. It means that the only type of homebirth that hospital providers see is a failed homebirth, which naturally colors their opinions on the success of the process. They never see the beautiful, peaceful, uneventful, successful homebirths. Instead, they can sometimes feel like they are being asked to “clean up the mess” made by homebirth midwives’ mismanagement, and the crazy people who are stupid enough to attempt birth at home. The attitude of the staff at the hospital and the way they act towards the incoming transfer is crucial. Either they can be respectful and positive, or judgmental and negative.

So, at the moment, we have plenty of people in New York city attempting homebirth with no back-up hospital to go to. We have midwives who don’t know where or to whom to bring their patients if they need assistance. We have couples trying to give birth who face potential castigation at the hospitals they may end up at.

I’m not really sure what happened to the couple last night. I got a text from my sister midwife whom I work with who told me that the homebirth midwife and her clients would be heading our way, but they never actually showed up. I was concerned because last night was actually really busy, and we didn’t have any extra beds to accommodate them. I actually ended up delivering a beautiful 9 lbs. 6 oz baby in triage last night, and the other midwife I was working with had to do a delivery in the recovery room–both of these on stretchers and not actual beds, which is never ideal. I know for a fact that we would have been kind and welcoming to any incoming homebirthers (we meaning the midwives…I can’t vouch for what the attitude of the doctors and nurses we worked with last night might have been, although I’d like to think that they would be pretty open and respectful, given that so many midwives work at our hospital). In any case, the couple never showed up. I can only hope that either they were able to successfully push the baby out at home without needing a vacuum, or else they chose to go to a different hospital than ours.

I can only hope that the homebirth midwives of New York City will be able to find back-up physicians at other hospitals and sign new WPAs/ get new admitting privileges soon, so a situation like this where a homebirth midwife is faced with such a difficult challenge doesn’t occur again any time soon.